Health inspections
Federal rules call for a standard inspection at least every 15 months, plus a visit whenever a complaint is filed. Each mark below is one citation, colored by how serious inspectors rated it. How to read a citation.
Under each citation, the quoted text is the inspector's own summary from the federal statement of deficiencies (CMS form 2567), word for word apart from a privacy scrub; CMS removes residents' and staff names before it publishes the text. The full notes are on Medicare.gov.
Potential for minimal harm Potential for more than minimal harm Actual harm Immediate jeopardy Found on a complaint visit
Where its citations fall on CMS's grid
CMS rates every citation by how much harm it caused (rows) and how many residents it touched (columns). The count in each box is this home's, across all 48 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
2J
0K
0L
Actual harm
4G
0H
0I
Potential for more than minimal harm
37D
5E
0F
Potential for minimal harm
0A
0B
0C
July 27, 2026Complaint inspection · 2 citations
- D
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Inspectors wroteBased on interview and record review, the facility failed to protect the resident's rights to be free from verbal and physical abuse by Resident 1, for 2 of 7 residents (Resident 2 and 3) reviewed for abuse. This failure placed the residents at risk for additional verbal and physical abuse, serious pain and injury, and emotional distress.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on interview and record review, the facility failed to ensure adequate supervision to prevent resident-to-resident altercations with Resident 1, for 2 of 7 residents (Resident 2 and 3) reviewed for accidents. This failure placed the residents at risk for continued resident-to-resident altercations, abuse, and dissatisfaction with their homelike setting.
April 13, 2026Complaint inspection · 1 citation
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure infection control measures intended to mitigate the transmission of Respiratory syncytial virus [(RSV) a virus that causes infections of the respiratory tract) were consistently implemented for contact precautions (infection control measures used to prevent the spread of germs that include wearing gloves and gowns when entering an isolation room, and performing meticulous hand hygiene with soap and water) and droplet precautions (infection control measures used alongside standard precautions to prevent the spread of pathogens transmitted through large respiratory droplets) for 2 of 4 staff (Staff B and Staff D) reviewed for infection control. This failure placed the residents at risk for contraction of communicable diseases, illness, and death.
March 4, 2026Complaint inspection · 3 citations
- E
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Inspectors wroteBased on observation, interview, and record review, the facility failed to implement written abuse policies and procedures for identification, protection and prevention of abuse for 4 of 6 residents (Residents 1, 2, 3, and 4) reviewed for abuse. This failure placed residents at risk of unidentified abuse, continued exposure to abuse and psychosocial harm.
- D
Let each resident or the resident's legal representative access or purchase copies of all the resident's records.
Inspectors wroteBased on interview and record review, the facility failed to provide copies of medical records within two working days as required for 1 of 1 resident (Resident 5), reviewed for access to medical records. Additionally, the facility failed to ensure its medical records policy was consistent with regulations pertaining to skilled nursing facilities. This failure placed the residents and/or representative at risk of not being fully informed of services and treatments provided and violated their rights.
- D
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Inspectors wroteBased on interview and record review, the facility failed to prevent a resident-to-resident sexual altercation for 2 of 3 residents (Residents 1 and 2) reviewed for abuse. This failure placed residents at risk of abuse, psychosocial harm and emotional distress.
January 26, 2026Complaint inspection · 1 citation
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure infection control measures intended to mitigate the transmission of Clostridioides difficile [(C. diff) a highly contagious bacteria that causes severe diarrhea and inflammation of the colon] were consistently implemented for contact precautions (infection control measures used to prevent the spread of germs that include wearing gloves and gowns when entering an isolation room, and performing meticulous hand hygiene with soap and water) for 1 of 2 staff (Staff D) reviewed for infection control. This failure placed the residents at risk for contraction of communicable diseases, illness, and death.
January 20, 2026Complaint inspection · 1 citation
- D
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Inspectors wroteBased on interview and record review, the facility failed to implement policies and procedures related to screening potential staff to ensure the protection of residents against abuse, neglect, misappropriation, and exploitation, as shown by review of Notification of Background Check (BGC) Result forms for 1 of 4 nursing staff (Staff B) reviewed for criminal background checks. This failure allowed staff unsupervised access to residents without a valid criminal background check, placing the residents at risk for abuse, neglect, misappropriation, and exploitation.
December 17, 2025Complaint inspection · 2 citations
- E
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on interview and record review, the facility failed to maintain resident medical records that were complete, accurate, readily accessible, and systematically organized for 4 of 9 residents (Resident 1, 2, 3, and 4) reviewed for resident records. This failure placed the residents at risk for receiving care and services based on inadequate/inaccurate information.
- D
Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
Inspectors wroteBased on interview and record review, the facility failed to identify a designated interdisciplinary [(IDT) a group of healthcare professionals from different disciplines to help people receive the care they need] team member, appointed as the responsible party for coordinating care and communication with hospice, and implement the written agreement that ensured effective communication, collaboration, and coordination of care between the facility and the hospice (a specialized type of care focused on providing comfort and support to individuals nearing the end-of-life) provider for 1 of 1 residents (Resident 1) reviewed for hospice services. This failure placed the residents at risk of not receiving necessary care and services at end-of-life.
November 21, 2025Standard inspection · 7 citations
- E
PASARR screening for Mental disorders or Intellectual Disabilities
Inspectors wroteBased on interview and record review, the facility failed to ensure residents Preadmission Screening and Resident Review ([PASARR], an assessment to ensure individuals with serious mental illness [SMI] or intellectual/developmental disabilities [ID/DD] were not inappropriately placed in nursing homes for long term care) were accurately completed prior to admission and updated when new SMIs were identified and had the required Level II (a comprehensive evaluation by the appropriate state-designated authority) referral if residents had a positive Level I (a pre-screening evaluation for identifying SMI/ID/DD) PASARR for 6 of 6 residents (Residents 9, 43, 78, 31, 6, and 58 ) reviewed for PASARR and unnecessary medications. This failure placed the residents at risk of not receiving the mental health care and services appropriate for their needs.
- D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on observation, interview, and record review, the facility failed to promote a dignified living experience for 1 of 3 residents (Resident 73) reviewed for resident rights. This deficient practice placed residents at risk for humiliation, diminished self-worth, and infection control concerns.
- D
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure psychotropic (drugs that affect how the brain works, and cause changes in mood, awareness, thoughts, feelings, or behavior) medications were monitored for effectiveness using individualized, resident-specific targeted behaviors for 3 of 5 residents (Resident 9, 43, and 31) reviewed for unnecessary medications. This failure placed residents at an increased risk for experiencing medication-related adverse side effects and unmet care needs.
- D
Ensure services provided by the nursing facility meet professional standards of quality.
Inspectors wroteBased on interview and record review, the facility failed to follow professional standards of practice related to adding a new mental health diagnosis for 1 of 5 residents (Resident 31) reviewed for psychotropic (drugs that affect how the brain works, and cause changes in mood, awareness, thoughts, feelings, or behavior) medication use. This deficient practice placed residents at risk for unnecessary medications and unmet care needs.
- D
Provide or get specialized rehabilitative services as required for a resident.
Inspectors wroteBased on interview and record review, the facility failed to ensure physician ordered physical therapy (PT) was received in a timely manner for 1 of 3 residents (Resident 34) reviewed for specialized rehabilitation services. This failure placed the resident at risk for decline in function and/or not achieving the highest practicable level of physical, mental, and functional well-being.
- D
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Inspectors wroteBased on interview and record review, the facility failed to offer and/or provide an influenza (a common viral infection that attacks the lungs, nose, and throat) immunization for 1 of 5 residents (Resident 58) reviewed for immunizations and infection control. This failure placed the residents at risk for illness and transmission of communicable diseases.
- D
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an effective pest control program that ensured insects (flies) were not congregating in rooms or on persons for 1 of 4 residents (Resident 73) reviewed for environment. This deficient practice placed residents at risk of infection and contributed to a less than homelike environment.
September 11, 2025Complaint inspection · 1 citation
- D
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Inspectors wroteBased on interview and record review, the facility failed to provide notification of discharge to the Resident's Representative (RR) for 1 of 3 residents (Resident 1) reviewed for notifications. This failure placed the residents at risk of not having their representatives involved in their health care decisions, and a delay in care and services. Resident 1 Review of the medical record showed Resident 1 was admitted to the facility on [DATE] with diagnoses including follow-up care for a surgical procedure, heart failure and dementia (a progressive disease that destroys memory and other important mental functions). The cognitive assessment dated [DATE] showed Resident 1 had a severely impaired cognition. Record review of a discharge summary progress note dated 08/31/2025, showed Resident 1 was discharged to another facility. [...]
August 14, 2025Complaint inspection · 1 citation
- D
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Inspectors wroteBased on interview and record review, the facility failed to ensure staff implemented fall prevention interventions identified on the resident's care plan for 1 of 3 residents (Resident 1) reviewed for falls. This failure placed the residents at risk for repeated falls and injuries.
June 25, 2025Complaint inspection · 1 citation
- D
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Inspectors wroteBased on interview and record review, the facility failed to protect the resident's right to be free from verbal abuse for 1 of 3 residents (Resident 1) reviewed for abuse/neglect. This failure placed the residents at risk of experiencing fear, intimidation, mental anguish, and emotional distress.
May 23, 2025Complaint inspection · 2 citations
- D
Honor the resident's right to receive visitors of his or her choosing, at the time of his or her choosing.
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure visitation rights were protected for 1 of 1 resident (Resident 2) when an immediate family member was limited to specific visitation hours indefinitely. This failure placed residents at risk of isolation, depression, and a diminished quality of life.
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on observation, interview, and record review the facility failed to report allegations of abuse and/or neglect to the State Agency for 2 of 4 residents (Residents 3 and 4) reviewed for grievances. This failed practice placed residents at risk for not receiving care and services and unidentified and on-going abuse and/or neglect.
March 6, 2025Complaint inspection · 1 citation
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview and record review the facility failed to ensure standard infection control interventions intended to mitigate the risk for transmission of COVID-19 [an infectious disease causing respiratory illness with symptoms including cough, fever, new or worsening malaise (a general feeling of discomfort/uneasiness), headache, dizziness, nausea, vomiting, diarrhea, loss of taste or smell, and in severe cases, difficulty breathing that could result in severe impairment or death] for 3 of 4 staff (Staff D, E, and F) reviewed for personal protective equipment [(PPE) clothing and devices that protect workers from exposure to injury or infection]. Additionally, the facility failed to ensure COVID-19 testing was completed every three days as directed by the Local Health Jurisdiction for 3 of 5 residents (Resident 1, 2, and 3) reviewed for COVID-19 testing. [...]
January 13, 2025Complaint inspection · 1 citation
- D
Ensure services provided by the nursing facility meet professional standards of quality.
Inspectors wroteBased on observations, interviews and record review, the facility failed to ensure staff followed acceptable standards of practice regarding medication administration for 1 of 3 residents (Resident 1), reviewed for narcotic pain medication. Resident 1's narcotic pain medication was not available to administer to the resident as it was not ordered timely by staff when the supply became low. In addition, scheduled agency staff and newly hired staff did not have authorization codes to use the Omnicell (emergency dispensing machine for medications). Administrative staff made no attempt to call the pharmacy to determine an action plan based on scheduled staff not having access to the Omnicell, nor did any LNs come to the facility to obtain the narcotic medication for the resident. [...]
October 3, 2024Complaint inspection · 2 citations
- G
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on observation, interview, and record review, the facility failed to identify avoidable accident hazards during a mechanical lift transfer for 1 of 3 residents (Resident 1) reviewed for falls. Resident 1 experienced harm when they fell to the floor from the mechanical lift and sustained a hematoma (a collection of blood that forms outside of blood vessels, usually caused by an injury or trauma) and an abrasion to the forehead, requiring a transfer to the emergency room.
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on interview and record review, the facility failed to report a fall with significant injury to the State Agency as required, experienced by 1 of 3 residents (Resident 1), reviewed for falls. This failed practice placed the residents at risk for harm and diminished protection and oversight from the State Agency.
August 26, 2024Standard inspection · 6 citations
- J
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that four-point restraints (a device used to support impaired posture that restricts a resident's freedom of movement) were applied in a safe manner, and failed to establish the medical need for the restraint, implement assessments, care planning, and supervision that focused on the specific restraint use for 2 of 2 residents (Residents 1 and 5), reviewed for physical restraints. This failed practice placed Resident 1 at serious risk of entrapment, strangulation, and death, and placed both Resident 1 and Resident 5 at risk for a decline in physical function, restriction of free movement, risk of injury, loss of dignity, and was determined to be an immediate jeopardy. [...]
- J
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on observation, interview and record review the facility failed to ensure food was served at a safe temperature for 1 of 3 resident's (Resident 48) reviewed for avoidable accidents. This failure resulted in injury and pain to Resident 48 and placed other residents at risk for serious harm and injury related to the unsafe temperatures of reheated food in microwaves. Additionally, the facility failed to ensure resident safety was maintained for 2 of 3 shower rooms in the transitional care unit (TCU and 300 hall) and 8 of 8 personal protection equipment (PPE) carts reviewed for accidents and hazards by securing potentially hazardous cleaning agents. These failures placed resident's at risk for harm in the event the cleaning agents were ingested or skin/eye exposure. [...]
- E
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure restorative nursing services programs including the consistent use of braces/splints were implemented for 2 of 3 residents (Resident 22 and 31), reviewed for restorative nursing and limited range of motion [(ROM) the extent the joint can move within the expected (normal) range of values]. This failure placed the residents at risk for loss of ROM, deconditioning, and contractures (a permanent tightening of the muscles, tendons, skin, and surrounding tissues that causes the joints to shorten and stiffen).
- D
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Inspectors wroteBased on interview and record review, the facility failed to ensure dialysis services met professional standards of care for 2 of 2 residents (Residents 9 and 44) reviewed for dialysis (the kidneys no longer function and require a process to remove waste and excess fluids from the blood stream). The facility did not have an effective or coordinated process for communication between the facility and the offsite dialysis center for continuity of care. This failure placed residents receiving dialysis at risk for complications and unmet care needs.
- D
Provide or obtain dental services for each resident.
Inspectors wroteThe facility failed to coordinate a referral for denture services for 1 of 1 resident (Resident 33), reviewed for dental services. This failure placed the resident at risk for altered self-image and weight loss.
- D
Keep all essential equipment working safely.
Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain essential equipment in working condition, including 1 of 1 washing machine (Washer 2) and 1 of 1 kitchen exhaust fan (janitor closet fan), reviewed for functional essential equipment. The failure to ensure Washer 2 was in working condition placed the residents at risk for ineffective cleaning of laundry, lack of clean laundry, and cross contamination of infectious disease. Additionally, the failure to ensure the janitor closet fan was in working condition placed residents and staff at risk for inhalation of chemical fumes that could cause illness or breathing issues.
June 24, 2024Complaint inspection · 4 citations
- G
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on interview and record review, the facility failed to provide timely care and services and perform assessments for 1 of 3 residents (Resident 1) reviewed for changes in condition. Resident 1 experienced harm when they had prolonged bladder pain due to urinary retention with a delay in treatment.
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on interview and record review, the facility failed to ensure an incident of neglect was reported to the State Agency in a timely manner as required for 1 of 3 residents (Resident 1) reviewed for neglect. Failure to report to the State Agency placed residents at risk for additional neglect.
- D
Respond appropriately to all alleged violations.
Inspectors wroteBased on interviews and record review, the facility failed to thoroughly investigate incidents of neglect for 1 of 3 residents (Resident 1) reviewed for investigations. This failed practice placed all residents at risk for not identifying corrective actions to prevent further neglect.
- D
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Inspectors wroteBased on interviews and record review the facility failed to ensure 1 of 1 Licensed Nurse (Staff B), reviewed for competency, demonstrated competency in caring for Resident 1, who was experiencing a change of condition. In addition, the facility failed to ensure Staff B was evaluated by the facility for competency with skills and techniques prior to working. This failure placed Resident 1 at risk for clinical complications.
May 23, 2024Complaint inspection · 1 citation
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on observation, interview, and record review, the facility failed to provide adequate supervision and ensure appropriate interventions were thoroughly implemented to prevent avoidable accidents for 1 of 3 residents (Resident 1) reviewed for accidents. Resident 1 experienced leg wounds while using their motorized wheelchair (w/c). This failure placed Resident 1 at risk for medical complications from the repeated leg wounds.
March 20, 2024Complaint inspection · 1 citation
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on interview and record review, the facility failed to obtain and monitor blood glucose levels [a measurement of the amount of glucose (sugar) in the blood] for 1 of 3 residents (Resident 1) reviewed for quality of care. This failure placed the resident at risk for worsening of their diabetes mellitus [(DM) a disease that occurs when the amount of sugar in the blood is too high], unidentified care needs, and poor clinical outcomes.
February 12, 2024Complaint inspection · 2 citations
- D
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Inspectors wroteBased on interviews and record review the facility failed to notify the resident's responsible party of significant changes in condition in a timely manner for 1 of 3 residents (Resident 1) reviewed for notification of changes. The failure to notify the responsible party placed the resident at risk of not having them involved in the heatlh care decision making process for timely care and services.
- D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on interviews and record review the facility failed to ensure the medical records were accurate for 1 of 5 residents (Resident 1) reviewed for complete medical records. This failure placed Resident 1 at risk for not having accurate information and possible harm if inaccurate information was used to make medical decisions.
September 21, 2023Complaint inspection · 4 citations
- G
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Inspectors wroteBased on observation, interview and record review, the facility failed to identify incidents of verbal abuse in a timely manner, failed to protect the resident's right to be free from verbal abuse and take timely action to prevent further abuse as a State agency was not notified until 09/08/2023 (four months later) for 1 of 3 residents (Resident 1) reviewed for abuse. Despite multiple staff interviews of witnessed abuse to Resident 1 by their representative (RR) the abuse continued for four months which caused psychological harm to Resident 1 as displayed by the resident crying, asking why the RR was so mean to them and sadness.
- D
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Inspectors wroteBased on interviews and record review the facility failed to implement written abuse policies and procedures relative to the required identification, abuse reporting, investigation and protection for 1 of 1 resident (Resident 1) reviewed for abuse. These failures placed all residents at risk for potential and/or further abuse.
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on interviews and record review the facility failed to ensure allegations of verbal abuse were reported to the State survey agency in a timely manner for 1 of 1 (Resident1) reviewed for abuse reporting. This failure placed Resident 1 at risk for unidentified verbal abuse and lack of protection due to prolonged, unrecognized abuse by their representative (RR).
- D
Respond appropriately to all alleged violations.
Inspectors wroteBased on interviews and record review the facility failed to conduct thorough investigations on multiple witnessed incidents of verbal abuse to 1 of 1 resident (Resident 1) reviewed for abuse. This placed the resident at risk for repeated incidents of abuse.
June 29, 2023Standard inspection · 4 citations
- G
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a resident was treated with dignity/respect in a manner that promoted the resident's choice to smoke independently without fear of intimidation or reprisal (an act of retaliation) for 1 of 2 residents (Resident 33), reviewed for the resident right to smoke cigarettes independently. Additionally, the facility failed to protect Resident 33 from ongoing staff reproach (the expression of disapproval or disappointment) when Resident 33 exercised their right to smoke cigarettes outside facility grounds. [...]
- E
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications, biologicals, and testing supplies were stored, labeled, dated, or discarded when expired for 2 of 3 medication rooms (Team 2 and Team 3), and 1 of 3 (Transitional Care Unit, cart B - TCU B) medication/treatment carts reviewed. Additionally, the facility failed to consistently monitor temperatures for the storage of vaccines (A preparation that is used to stimulate the body's immune response against diseases) for 2 of 2 medication refrigerators (Team 2 and Team 3) reviewed. These failures placed residents at risk of receiving compromised or ineffective medications.
- D
Ensure services provided by the nursing facility meet professional standards of quality.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure services provided met professional standards of practice to ensure that physician ordered parameters for narcotic pain medications were followed and documented accurately by licensed nurses (LNs) for 5 of 6 residents (202, 207, 208, 209, and 210) reviewed for following physician orders. This failed practice placed residents at risk for medication errors, a delay in treatment, and adverse outcomes.
- D
Provide care or services that was trauma informed and/or culturally competent.
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that resident's who were trauma survivors received culturally competent, trauma-informed care in accordance with professional standards of practice by not assessing, monitoring, or treating past experiences of post traumatic stress disorder (PTSD, a disorder that develops when a person has experienced or witnessed a scary, shocking, terrifying, or dangerous event) and sexual assault for 2 of 3 residents (Residents 7 and 202), reviewed for mood and behavior. This placed the residents at risk for unidentified triggers, re-traumatization, and a decreased quality of life.
Fire safety inspections
39 fire safety citations on file: 21 on November 21, 2025, 16 on August 26, 2024, 2 on June 29, 2023.
Every fire safety citation39 citations
- F
Develop and maintain an Emergency Preparedness Program (EP).
E 4 · November 21, 2025 · Corrected (the home has a date of correction)
- F
Conduct risk assessment and an All-Hazards approach.
E 6 · November 21, 2025 · Corrected (the home has a date of correction)
- F
Address patient/client population and determine types of services needed.
E 7 · November 21, 2025 · Corrected (the home has a date of correction)
- F
Include a process for Emergency Preparedness collaboration.
E 9 · November 21, 2025 · Corrected (the home has a date of correction)
- F
Establish policies and procedures for volunteers.
E 24 · November 21, 2025 · Corrected (the home has a date of correction)
- F
List the names and contact information of those in the facility.
E 30 · November 21, 2025 · Corrected (the home has a date of correction)
- F
Provide primary/alternate means for communication.
E 32 · November 21, 2025 · Corrected (the home has a date of correction)
- F
Establish emergency prep training and testing.
E 36 · November 21, 2025 · Corrected (the home has a date of correction)
- F
Establish staff and initial training requirements.
E 37 · November 21, 2025 · Corrected (the home has a date of correction)
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · November 21, 2025 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · November 21, 2025 · Corrected (the home has a date of correction)
- F
Install corridor and hallway doors that block smoke.
K 363 · November 21, 2025 · Corrected (the home has a date of correction)
- F
Have properly installed electrical wiring and gas equipment.
K 511 · November 21, 2025 · Corrected (the home has a date of correction)
- F
Have simulated fire drills held at unexpected times.
K 712 · November 21, 2025 · Corrected (the home has a date of correction)
- F
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
K 761 · November 21, 2025 · Corrected (the home has a date of correction)
- F
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · November 21, 2025 · Corrected (the home has a date of correction)
- F
Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk.
K 926 · November 21, 2025 · Corrected (the home has a date of correction)
- E
Properly select, install, inspect, or maintain portable fire extinguishes.
K 355 · November 21, 2025 · Corrected (the home has a date of correction)
- E
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · November 21, 2025 · Corrected (the home has a date of correction)
- D
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
K 223 · November 21, 2025 · Corrected (the home has a date of correction)
- D
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
K 362 · November 21, 2025 · Corrected (the home has a date of correction)
- F
Address patient/client population and determine types of services needed.
E 7 · August 26, 2024 · Corrected (the home has a date of correction)
- F
Address subsistence needs for staff and patients.
E 15 · August 26, 2024 · Corrected (the home has a date of correction)
- F
Create arrangements with other facilities to receive patients.
E 25 · August 26, 2024 · Corrected (the home has a date of correction)
- F
List the names and contact information of those in the facility.
E 30 · August 26, 2024 · Corrected (the home has a date of correction)
- F
Establish staff and initial training requirements.
E 37 · August 26, 2024 · Corrected (the home has a date of correction)
- F
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · August 26, 2024 · Corrected (the home has a date of correction)
- F
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
K 321 · August 26, 2024 · Corrected (the home has a date of correction)
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · August 26, 2024 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · August 26, 2024 · Corrected (the home has a date of correction)
- F
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · August 26, 2024 · Corrected (the home has a date of correction)
- D
Develop and maintain an Emergency Preparedness Program (EP).
E 4 · August 26, 2024 · Corrected (the home has a date of correction)
- D
Conduct risk assessment and an All-Hazards approach.
E 6 · August 26, 2024 · Corrected (the home has a date of correction)
- D
Properly select, install, inspect, or maintain portable fire extinguishes.
K 355 · August 26, 2024 · Corrected (the home has a date of correction)
- D
Install corridor and hallway doors that block smoke.
K 363 · August 26, 2024 · Corrected (the home has a date of correction)
- D
Have properly installed electrical wiring and gas equipment.
K 511 · August 26, 2024 · Corrected (the home has a date of correction)
- D
Ensure proper usage of power strips and extension cords.
K 920 · August 26, 2024 · Corrected (the home has a date of correction)
- E
Install corridor and hallway doors that block smoke.
K 363 · June 29, 2023 · Corrected (the home has a date of correction)
- D
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
K 321 · June 29, 2023 · Corrected (the home has a date of correction)